Rural surgery has always been and remains an important part of our nation’s health care delivery system, as an estimated 60 million people live in rural areas in the U.S.* I am a board-certified general surgeon, and I practiced in a rural area of northwest Kansas for many years. The population of the town where I practiced, Hill City, KS, was approximately 3,000 and the county population was approximately 4,000 when I moved there in the 1970s. Now I am retired, and I want to tell my story.
How I wound up in rural Kansas
People ask me how I wound up in a small town like Hill City, KS. I came from India and did my internship and residency in surgery at Misericordia Hospital and at Knickerbocker Hospital in New York, NY. After finishing my general surgery residency, I did one year of plastic surgery training at Upstate Medical Center, Syracuse, NY. In those days, most young surgeons wanted to go into private practice or join a group practice. In my case, I was uncertain whether patients would come to see me since I am from a foreign country.
I found an ad in one of the medical journals and discovered that the Graham County Hospital in Hill City was looking for a physician. I called the hospital and the chief executive officer (CEO) asked me to come for an interview. I agreed. I flew to Hays, KS, the location of the closest airport to Hill City, and the CEO of the hospital came to the airport to greet me.
At the time, I did not realize Hill City was a small town. I knew the location by looking at the map, but I was not aware of the area’s population size. The CEO took me around Hill City and then to the hospital, where he introduced me to the hospital board members; they offered me the job, and I accepted.
A rewarding and busy practice
In late summer of 1973, I moved with my wife and my son, who was two years old at the time, to Hill City from New York City. The day after our move, I started seeing patients. A few days later, the CEO of the hospital took me to his house. His wife told me, “I heard that people like you.” I was glad to hear that, as my work motivation was to take care of patients to the best of my ability and knowledge. Fortunately, it did not take long for me to get established.
I started performing major operations in the fall of 1973. Harl Stump, MD, FACS, a general surgeon in Hays, would assist me in major cases. Without his help, I could not have done major operations. A pediatrician colleague by the name of B. N. Reddy, MD, also helped me with some major cases.
I practiced in Hill City for 41 years. In those 41 years, I performed the following procedures, among many others:
- Tonsillectomy and adenoidectomy: 144
- Appendectomy: 255
- Herniorrhaphy: 266
- Carpal tunnel release: 181
- Cholecystectomy: 351
- Open cholecystectomy: 219
- Laparoscopic cholecystectomy: 132
- Thyroidectomy: 18
- Gastroscopy: 1,053
- Sigmoidoscopy: 104
- Colonoscopy: 709
When I was in training, all cholecystectomies were open. I read about laparoscopic cholecystectomy (lap chole) in a surgical journal. At that point, I went to St. Louis, MO, to practice on animals. Subsequently, I went to Salina, KS, to learn more. Dr. Stump also helped me do laparoscopic cholecystectomy.
Other operations that I performed ran the gamut of general surgery, plastic surgery, and obstetrics-gynecology (OB-GYN)—from gastrostomy tube replacement to radical mastectomy; from wound closure with flap to removal of foreign bodies, including bullets and screws; and from cesarean section (C-section) to hysterectomy.
I had several books on operating procedures. Many times I would read up on a procedure the day before an operation like hysterectomy or C-section, and do the case the next morning.
I did two cases of parathyroidectomy, despite not having done the procedure in my training. I learned from reading articles. In the 1970s I also did a few cases of gastrojejunostomy, vagotomy, and pyloroplasty. In those days, there were no proton pump inhibitors like Nexium or Protonix. If the patient did not respond to H-2 blockers and continued to have symptoms of peptic ulcer, we had to operate.
I also did a few cases of orthopaedics, such as open reduction and internal fixation of fractures of medial malleolus or lateral malleolus. When I was in training, I would help orthopaedic surgeons doing all these cases.
Fortunately, I rarely encountered complications. I recall two cases with common bile duct injury while doing lap chole. I sent those patients to a different hospital, where they received appropriate surgical care.
When I first started in Hill City, I did not realize I was supposed to perform deliveries. One day I was talking to the CEO of the hospital in the hallway, and he said a patient, who was clearly pregnant, was waiting to see me. I was kind of surprised. That was when I started doing deliveries. I did not have much experience as a resident doing deliveries, although as part of medical school training, I did rotations in OB-GYN.
I was trained at a private hospital in New York City that had no OB-GYN residency program. As a surgical resident at Knickerbocker Hospital, I helped with C-sections and hysterectomies, and that is how I learned to do these operations. I also learned from another physician, Carl Kobler, MD. The adage of “see one, do one, teach one” applied to me, for sure.
A woman came to my office with labor pains. She was full-term and was having contractions. Her cervix was approximately 9 cm dilated. I could feel the head of the fetus. I told her, “You better go to the hospital now. I’ll follow you, and I will deliver the baby at the hospital.” The woman said, “Doc, my friend who dropped me here went shopping. I have to wait for her to come and pick me up and take me to the hospital.” I told her, “There is no time to wait. You’d better go to the hospital now.” She said, “Doc, I’m sorry, I have no transportation.” So, I took the patient in my car to the hospital, where I delivered the baby. I do not think you will see many physicians in non-rural areas taking the patient to the hospital as well as delivering the baby.
I once delivered two babies minutes apart. Two mothers came to the hospital in labor, almost at the same time. They were placed in separate rooms. I examined both of them, and the cervix of each patient was fully dilated. I went to one room, delivered the baby, tied and cut the umbilical cord, and handed the baby to the nurse. Another nurse came and said, “Oh, Doc, the other patient is having more pain.” I had no time to change my gown. I just changed my gloves, ran to the other room, delivered the baby, tied and cut the umbilical cord, and gave the baby to the nurse. Then I went back to the first room, changed gloves, and delivered the placenta. I went back to the second room, changed gloves, and delivered the placenta. Both newborns did well.
I slept many nights in the physician’s lounge, waiting to deliver babies. As you know, when the cervix is 6–8 cm dilated, the baby is nearing birth, so I did not want to go home and come back right away. So I just slept in the doctor’s lounge, and when the nurse called from the delivery room, I would go and deliver the baby. In all, I delivered 523 babies. There was one breach presentation. I also delivered one set of twins. I applied forceps on three occasions to deliver the babies; two babies were, unfortunately, stillborn.
ACS supports rural surgery
I recall these experiences fondly today. They have stuck with me over the years, and that’s why it is disheartening to see so few young surgeons pursuing careers in rural surgery. The American College of Surgeons (ACS) has sought to address the unique needs of rural surgeons by establishing the ACS Advisory Council for Rural Surgery and the Rural Surgery track at the annual Clinical Congress. In addition, ACS Fellows were involved in the launch of the Society for Young Rural Surgeons (SYRUS). The mission of the society is to increase the awareness of medical trainees and practitioners of the surgical workforce needs of rural areas (at home and abroad) and to provide training and career support for these surgeons. According to SYRUS, 10 universities in states that have many rural communities have rural surgery residency programs. These programs provide trainees with skills and the knowledge needed to practice in the rural areas. Residents attain broad-based general surgery training, but also rotate through high-demand surgical specialties, including otolaryngology, urology, orthopaedics, and OB-GYN.
Rural surgical practices offer many advantages, including greater autonomy and opportunities to offer personalized services to the people who are your neighbors. Of course, it has disadvantages as well, including isolation, both professional and personal; difficulty getting coverage; and greater burden of on-call duty.
If you want to practice surgery in a rural area, you have to be prepared to do a wide range of procedures, and it is better to be familiar with as many as possible. The motivation should be to make the patient better. Do your best without thinking too much about reimbursement.
It also helps to have personal and professional support. I want to thank the nursing staff at Graham County Hospital, Hill City, for their help over the years. I also want to thank Dr. Stump for assisting in major cases and Dr. B. N. Reddy for assisting in C-sections and other cases. Last but not least, I want to thank my wife, Nalini, for her support. You cannot practice successfully without support from your loved ones.
*Tanner K. Census: Michigan’s rural areas top urban areas in income, home values. Detroit Free Press. December 8, 2016. Available at: www.freep.com/story/opinion/contributors/raw-data/2016/12/08/census-new-data-outline-urban-rural-divide/95085072/. Accessed January 9, 2017.